Motherhood at Peril

By Priya Subramanian, Save the Children Media Manager. This article also appeared in The Hindu.

Are the mothers of India safe? A vast majority of them do not have access to basic health care...

Thirty-year-old Naseem Bano is a mother of five who makes a living rolling beedis at home in Tonk district of Rajasthan. Naseem's last child was born in a hospital. Her first four children were delivered at home. She had one miscarriage before her last son was born. According to Naseem, “she was too scared to go to a hospital for delivering her first four children.” Crucially, her husband would not allow her to go to a hospital with a male gynaecologist.

Naseem's story is shared by millions of women in India and across the developing world. Today, the world over, a day has been dedicated to celebrate the mother. Underlying the warm eulogies of the woman donning different roles as mother, sister, wife, etc, there is another subaltern narrative of the woman who has never been to school, who has no control over resources in her own home, and who will be dictated to by her husband and the elders in the family on whether she can go to hospital to deliver her child.

No infrastructure

Every year, 50 million women in the developing world give birth at home with no professional help whatsoever. And every year, nearly 350,000 women die during pregnancy or childbirth. Almost all these deaths happen not because of untreatable complications but because these mothers do not have access to basic health care services or if these are available, they are of very poor quality.

Most of these deaths could be prevented if skilled and well-equipped health care workers were available to serve the poorest, hardest to reach mothers. However, there is a very strong link between whether a woman can access skilled health care and her level of education. Poorer and less educated women, and especially those living in rural areas, are far less likely to give birth in the presence of a skilled health worker than better educated women who live in wealthier households.

A UNESCO report says worldwide, 39 million girls are not attending school and millions more complete only a year or two of schooling. In India, female literacy stands at a disappointing 53.67 per cent. Women like Naseem with little or no schooling lack the confidence and authority to make decisions for their own health and the health of their children.

Moreover, social and cultural barriers often prevent women like Naseem from visiting health providers. Typically, in rural areas, husbands and elder family members often decide whether a woman may go for health care outside the home and women themselves often choose to forego health care if the provider is male due to social stigma. In such circumstance, the presence of a skilled female health care provider could mean the difference between life and death for the mother and her newborn child.

Experience in many countries has shown that modest investments in female community health workers can have a strong impact on mothers surviving in rural communities. Between 1990 and 2008, Bangladesh has cut its maternal mortality rate dramatically by 53 per cent. In 1997, the government launched a safe motherhood initiative aimed at improving emergency obstetric care and training 17,000 skilled birth attendants to work at the community level. Though still more than 116,000 mothers die each year in Bangladesh mainly because of inadequate care during childbirth, a vibrant home-grown NGO sector has shown that health workers with limited education and training can have a significant impact on the survival of mothers.

Recent findings presented in The Lancet indicating a 1.5 per cent yearly rate of decline in maternal mortality since 2005 is good news. In India, the National Rural Health Mission has completed five years this year. Despite good schemes, their implementation leaves a lot to be desired. A recent Comptroller and Auditor General report found that institutional deliveries have not really taken off due to several irregularities in the States where maternal mortality and infant mortality rates are high. Only 47 per cent of women give birth attended by skilled health attendants.

Poor health care

In 2000, India, along with 189 Heads of State and government committed to reducing the numbers of mothers dying by 2015 in their Millennium Declaration. Despite a decline in maternal mortality rate, the question arises if we are doing enough to save the lives of thousands of mothers who are still dying because there is no health care provider nearby to spot complications early on and intercede on behalf of these mothers before it is too late.

A worldwide survey done recently by Save the Children finds India at 73 out of 77 middle-income countries in terms of the best country to be a mother. To paraphrase Nehru, you can tell the condition of a nation by looking at the status of its women. In a country that has glorified women in mythology and fiction, it is incongruous to have a reality where women have no control over their destiny and indeed their lives and, are dying because they cannot access basic health care.